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HomeMy WebLinkAboutBuilding Permit #337-10 - 275 CHESTNUT STREET 10/21/2010 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: 0 Date Received_ l0 Date Issued t2, - IMPORTANT: Applicant must complete all items on this page LOCATION P 'nt PROPERTY OWNER Print MAP NO:OgP- C PARCELOOO-1 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Resi ntial Non- Residential ❑ New Building NKOne family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑Floodplain ❑ Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION��j O_RK TO BE PERFORMED: identification Jflease T�jp or P an Cle 1Y) OWNER: Name: �l� �— �i�GL� Phone: Address b� �� C ��S�it��% �� �2,� CONTRACTOR Name: L//�'�G�/ S ��.f���iG�, one: � � Address: �,J'' Supervisor's Construction License: Exp. Date: Home Improvement License: �/ 4�'rExp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT'$12.00�PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ Gcj FEE: $ CJ Check No.: �aReceipt No.: � � NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contract .,/ Location ;' r 6"'On $'/_ ll No. ?5Q= Date � U NORTH TOWN OF NORTH ANDOVER O F R �aCertificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ �TOTAL $ Check # _.rte 235 ! Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Siqnature COM19FrNTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Siqnature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi NORTH TO" o6 ove r 0 V" No. _ LAKE o dover, Mass., COCHICHEWICK V S RATEO pP�`�,�5 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....../..QM......... N .......................................................................................................... Foundation .... / has permission to erect....... buildings on .....at. .. ......... Rough to be occupied.as........ T.........ctc..1'LlP.a.. .......... ....... Chimney provided that the person acce ing this permit shall in every res ct conform to the term of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS U S TS Rough .... .................................................. .................... Service B G INSPECTOR Final Occupancy Permit Required to Ocmpy Building GAS INSPECTOR •I Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE Smoke Det. :Bonnie Welch FaxID:9784549343 Page 1 of 1 Date:10/21/2010 01:24 PM Page:1 of 1 CERTIFICATE OF LIABILITY INSURANCE OPID BW DAT CERTIFICATE QUINN-1 10/21/10 IFr DUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION anciss Provencher Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 530 Rogers Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lowell MA 01852 Phone: 978-459-8681 Fax:978-454-9343 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Penn—America INSURER B: Commerce Insurance Company 34754 Quinn's Construction INSURER C: 1368 Mammoth Rd. INSURER D: Dracut MA 01826 INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDNYYY) DATE(MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A x COMMERCIAL GENERAL LIABILITY PAC6862247 01/13/10 01/13/11 PREWSISES(Eaoccurence) $ 50000 CLAIMS MADE [X] OCCUR MED EXP(Any one person) $ 5'5000 PERSONAL BADV INJURY $ 1000000 GENERAL AGGREGATE $ 2000000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2000000 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ B ANY AUTO BBGS68 05/07/10 05/07/11 (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ 250000 HIRED AUTOS BODILY INJURY $ 500000 NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ 250000 (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION - - AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVEF-1E.L.EACH ACCIDENT $ OFFICER/Mt7MBER EXCLUDED9 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS **CERTIFICATE FOR WORKERS' COMP COVERAGE WILL BE ISSUED DIRECTLY FROM THE COMPANY WITHIN 2 BUSINESS DAYS** CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Town of N. Andover IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Building Dept. REPRESENTATIVES. fax (978) 688-9542 AUTHORIZED REPRES ATIVE 1600 Osgood St. Andover MA 01845 ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 9Ae -Co Office of Consumer Affairs andesiness Regulation 10 Park Plaza- Suite 5170 Boston,Massausetts 02116 Home Improvement QQnYtctor Registration Re_q'lstrafwn_ 121604 rz, Type: individual 'r----r-- 1�t r; 5/24/2012 Tr!! 293905 QUINN'S CONSTRUCTION _? THOMAS QUINN \� 868 MAMMOTH RD_ DRACUT, MA 01826 ; Update Address and return card.Mack reason for changes E] Address ❑ Renewal n Employment E] Lost Card DPS-cut w SOM4464GIOIZIG T.I. - Ucense or registration valid for individul use only 011'iee of Consumer Atlairs&Business Regala6on More the ezpiratioa date. If found return to: HOME ttitP ENT CONTRACTOR �. Office of Consumer Affairs and Business Regulation Registratiogl;.�21604 10 Park PLO=-Suite 5170 E>piTr# 293905. Basfou,lYtA02116 .. _— Ty QIjINN'S CONS3 THOMAS QUIN� 868 MAMMOTii_1 DRACUT,MA 01826 Undersecretary Not valid without signature Ni:tcs:tchusetts=Department of Public Safet% ! Resbitsedto: 00 Board of Building Reoulati0ns and Standards Construction Supervisor.Ucense 00- Unrestricted 1C-1 2 Faun*Homes License. CS 39732 } Restricted to: 00_: THOMAS J :QUINN . .Fatlate to possess a current edition of the 868 MAMMOTH FW i State Building Code pRACUT,MA-01M is cruse for-revocation of this WWrr� Refer to W _Mass.Gov/DPS Expiration:-3r25=2 f"ommic�iooc Tr#' 18M Tom Quinn (Contract Employer ID # (978) 265.2390 QUINN'S CONSTRUCTION 868 Mammoth Road • Dracut, Massachusetts 01826 Name / ` Date Street Add s(Not�Post tB � 5 C_ \ yob Name / � a_ -c) Citylfown, State&Zipcode �- I-lJ /V/�V�r �� Job Location Daytime P e: E`v#»iog ne: /civ J Mailing address(if different from above) Salesperson(s): > ✓ ontra or i " Q's Exp. Date: i V I We hereby submit specifications and estimates for: J S�C// .L� f��/ ,// /..f/ " /� %r /. ✓ " . :! /✓,..1 r— i�',� !S fig/ i � 'i.�.' �l �'! /a C.�J/ /^' �/�► �>J t� Imo/ ��rJ �!'� rr�l=!'7 r✓�— �C '�/✓,1 �/S/ / ,L�r'-� V/ % /� IR` l���iL� "/ / f/� ��/�/ ?C ,��/ '/ /a�/'✓/�C.Jf�~ LI J /;/t r --a .✓ � r'Fa .r./C GAJ /�. 7;/-''�� 3/ Y �� /. �:,=,J --'%. / - r11 J �.� -' /, / r ,r- / -►a... r/ i'/+ /,•:� S �'�� !'�%/ �(J r'' �,.�' �- / 'S�./. I' %..C��-'fr71 1� /'�J/,•�v�r C-•' '� f' s%" / ) .•� ' r�r/+=•r:? �• `7/� �/ !d• /�f• J CG../i '� %+N.C' /it-i� �J t G 1/i ../ C//'•.. Lam.. ,..! .> !7• /:/s.l r �1 /J��// •c''�u(✓i�l! +i °C� �C7�I�✓s�J,ir-�.. 11o/ C .✓ i >c.^ .--•G/� 'lam /' j �.v /'c C a .�� r � / ✓ Ste. / The following scheduled will be adhered to unless circumstances beyond the contractor's control arise: Work scheduled to begin:W44-1/2?1114/i Expected Date of Completion: (Date Contractor Will Be Contracted Work) (Date When Contracted Work Will Be Sustantially Completecli TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE THE CONTRACTOR _GREE TO PERFORM THE WORK, FURNISH THE MATERIALAND LABOR SPECIFIED ABOVE FOR THE SUM OF: *includes all finance charges in this amount* Payments will be made accordin to the following SCHEDULE: $2_ , pon signing contract(*Not to exceed 113 of the total contract price OR the cost of special order items, whichever is greater*). $ .' Od l By_/ 1_or upon completion of $ vUJ By�/ /_or upon completion of i �1 ate/ _---�,�-.. ---- -------------------------___--- -------- , - Vii.r - - -------------------- $ /;1,,L ',pon completion of the contract(*Law forbids demanding full payment until contract is completed to both parties'satisfaction In order to meet the completion schedule,the following material/equipment must be special ordered before the contracted work begins.('Law requires that any deposit or down payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contractor price or(b) the actual cost of any special equipment or custom made material which must be ordered in advance to meet the completion schedule*): $ to be paid for DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Identical copies of the contract shouldgo to the homeowner and the contractor } Home Owners Signature: All ' !r %• ;e f,,�� /7r r rl rr Date: Contractors Signature: Date: You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be his main office or branch thereof, provided you notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of the agreement. � � � f � y SCD i� ���.� /L.l.��� ��� �� � _ �� \ 4`\ The Commonwealth of Massachusetts Department of Industrial Accidents P. � i Office of Investigations : . 600 Washington Street It Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):����/ ��� Address: City/State/Zip: WA�9CC.1"/ fj tO0M Phone #: S(�' A,r�o7an employer?Check the propriate box: Type of project(required): L 1. SI am a emplo with 4. ❑ I air a general contractor and I 6. ❑Newconstruction employees full nd/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: b 0�0 � > Expiration Date: l Job Site Address: �, City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certifyynder the pains andpenalties ofpefjury that the information provided`above is rue an correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cavy workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen-nit or license is being requested,not the Department of Industrial Accidents. Should you Have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sur&that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future pen-nits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or pen-nit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia